HospitalInspections.org

Based on observation, interview, and record review, the facility's Governing Body failed to:

A. ensure the facility had adequate staffing to provide safe care from June 2019 through August 8, 2019. Refer to A0144

B. ensure written notification was given to the patients or families that included the facility decision, name of the hospital contact person, investigation of the grievance, and the date of the completion in 5 (Pt #'s 11, 12, 13, 14, and 15) of 6 grievances reviewed. Refer to A0123

C. ensure the facility had broad administrative on call coverage, when considering appropriateness of patient admissions and staff concerns.


On 8/8/2019 an interview with staff #4, the Chief Executive Officer confirmed the "administrative on call" role was shared between herself and 3 Nursing leaders.

A request to view the on call schedule was made. The document identified as 2019 BHC Administrative on call 2nd Revision July 24, 2019, was provided. Six (6) months of Administrative on call was documented on the on call schedule. The schedule began July 1, 2019, and ended January 5, 2020. August 17 - 25, 2019, (10 days) were covered by the facilities Director of Nursing. All other weeks were covered by the Chief Executive Officer (CEO). There was no evidence of sharing of the Administrative call schedule.

Confidential interviews with 3 facility staff confirmed they had been told all decisions affecting the facility and especially staff went through the CEO. All requests for additional staff were denied and all patients were accepted regardless of appropriateness for the facility units. All 3 staff confirmed their concerns of appropriate patient placement were not taken into consideration prior to admission. Interviews were kept confidential due to staff concern for retaliation.


Review of medical record for Patient #9 revealed, patient was highly aggressive. He wore an ankle monitor for home arrest and had a probation officer. He physically fought and injured a 15 year old peer, patient #4, kicking the male peer repeatedly after he was knocked down.

Review of patient #4's Medical record revealed, he was admitted 7/7/2019. On 7/26/2019, the 06:59 nurses note recorded "pain in joint and head after fight. was kicked in the hip area with falls (sic). Sustained hard fall hitting right side of head with breakage of skin due to fall. Complains of some headache but not the worst headache of life". No earlier nursing documentation was found in the patients medical record. On 7/26/2019, Pt #4 was sent to the Emergency Department for a CT and MRI of his head. (Computed Tomography and Magnetic Resonance Imaging) no injury identified.

A review of the aggressive male peer patient #9's medical record revealed the following:

He was admitted 7/22/2019. On 7/25/2019, 1930, "after shift change patient was in the day area on (sic) the nurses desk, had verbal altercation with male peer an threatening a male peer to have a fist fight. Staff verbally intervened but (sic) unable to follow direction and continue fighting with peers. Patient warned the consequence of behavior and unit guidelines agreement discussed. Safety precautions maintained related to aggression behavior, male peer fell on the ground patient continued kicking as staff tried to separate him".

Based on observation, record review, and interview, the facility failed to:

A) ensure written notification was given to the patients or families that included the facility decision, name of the hospital contact person, investigation of the grievance, and the date of the completion in 5 (Pt #'s 11, 12, 13, 14, and 15) of 6 grievances reviewed. Refer to A 0123 Notice of Grievance Decision



B) provide adequate staffing to ensure care in a safe setting on 4 of 4 unit in use. (unit 100, 200, 400 and unit 500) from June 2019 through August 8, 2019. Refer to A 0144 Care in a Safe Setting.

Based on interview and record review, the facility failed to ensure written notification was given to the patients or families that included the facility decision, name of the hospital contact person, investigation of the grievance, and the date of the completion in 5 (Pt #'s 11, 12, 13, 14, and 15) of 6 grievances reviewed.

This deficient practice had the likelihood to cause harm in all patients.


Findings:

Review of the facility grievance log on August 7, 2019, after 12:00 P.M. revealed the following:


PATIENT #11

Patient #11 filed a written complaint/grievance on 1-31-2019. Patient #11 complained that a staff nurse went into the dayroom and told the entire room that because Patient #11 was caught smoking, everyone would be under the microscope. Patient #11 felt like her privacy was violated.

There was an undated entry from Staff RN #12 that stated the patient considered the issue resolved once she was assured that the Staff nurse would be counseled on the issue.

There was an entry on 2-13-2019, by Staff #1 that stated the employee was counseled upon return to work on today's date.

There was no written notice to the patient with the facility decision, investigation, or completion date of the grievance.


PATIENT #12

Patient #12 filed a written complaint/grievance on 6-2-2019. Patient #12 complained that a staff member was violating his patient right as well as other patients on unit 500. Patient #12 said, this staff member was belittling the patients, as well as addressing them argumentatively and rude.

There was a written entry by Staff # 1 that was attached to the grievance dated 6-3-2019 that stated, he spoke with the patient and the patient expressed his concerns. The entry, stated Patient #12 wanted instructions provided to the staff member about her professional behavior and wanted no further action. The entry also stated the staff member listed in the grievance was counseled regarding the issue.

There was no written notice to the patient with the facility decision, investigation or completion date of the grievance.


PATIENT #13

Patient #13 filed a written complaint/grievance on 6-16-2019 regarding quality of care.

There was an entry on 6-16-2019, that stated, Staff #13 talked with patient and helped alleviate his worries. There was no investigation noted.

Patient filed a written complaint/grievance on 6-20-2019, regarding fear for his safety. There was an undated entry from Staff #13 that stated, staff spoke with the patient about this event and that the patient was satisfied per the conversation. No further action needed.

There was no indication of any action/investigation to ensure the safety of this patient documented.

There was no written notice to the patient with the facility decision, investigation, or completion date of the grievance.


PATIENT #14

Patient #14 filed a written complaint/grievance on 6-23-2019 regarding staff treatment of him.

There was an entry on 6-24-2019, by Staff #1 that stated, he spoke with Patient #14. Patient #14 made allegations that staff were evil. Patient #14 wanted to be left alone and asked Staff #1 to leave the room.

There was additional entry by Staff #1 that stated, no further action was needed at this time. Staff #1 noted, Patient #14 appears to have delusional thought, religious preoccupations and association with evil spirits.

There was no indication that indicated Staff #1 spoke with staff members to complete a thorough investigation of the allegation.

There was no written notice to the patient with the facility decision, investigation, or completion date of the grievance.


PATIENT #15

Patient #15 filed a written complaint/grievance on 6-1-2019, regarding infection control issues, privacy issues, and quality of care given to the patients.

There was a typed entry attached to the complaint dated 7-3-2019. The note stated, Staff #13 spent 45 minutes with this patient and she is very paranoid and psychotic and cannot keep her train of thought on task. Nothing further to investigate at this time.

There was no indication that Staff #13 spoke with anyone to complete a thorough investigation.

There was no written notice to the patient with the facility decision, investigation, or completion date of the grievance.


Staff #1 confirmed the above findings related to the grievance.


Review of the facility policy titled, "Complaint and Resolution Process" with a review date of 8-2018 revealed the following:

" ...All written complaints are considered grievances and require a written response to the complainant. All verbal complaints regarding abuse, neglect, patient harm, or compliance with CMS are also considered grievances.

...The appropriate Director or Supervisor will investigate the concern, complaint or grievance and document the facts and assessment on the QICR form.

The patient, a family member or the responsible party will be contacted within 7 business days in most cases if the concern, complaint or grievance is received in writing. The contact will be documented. The reportable outcome of the investigation will be documented and a follow-up letter sent to the patient, family member or responsible party when the investigation is completed, generally within 30 business days of the receipt of the original grievance ...

...The final written response is sent to the complainant within 30 business days unless extenuating circumstances cause the delay to exceed 30 days ..."

Based on observation, record review, and interview, the facility failed to provide adequate staffing to ensure care in a safe setting on 4 of 4 units in use. (unit 100, 200, 400, and unit 500) from June 2019 through August 8, 2019.


This deficient practice posed an Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and and possibly subsequent death.


Findings:

Unit 100

On 8/8/2019 during a tour of the unit, 2 pediatric patients one female and one male were observed on the unit. While the nurse was attending to the female patient's request, the younger male patient entered the nurses station looking for coloring books. The door to the adjacent unit was open allowing entrance from unit 100, a pediatric unit, into the adolescent unit nurses station.

The registered nurse returned to the station in time to redirect the pediatric patient out of the nurses station and the open doorway to the adolescent unit. The pediatric patient could have entered the adolescent unit had the nurse not returned and intercepted the child.

The pediatric nurses station was later observed to have a lower drawer that was opened by the surveyor. The draw contained many computer cords and patch cords for other electronic deices. These cords could be obtained by a pediatric patient when the nurses station was not occupied by the nurse. These cords were a ligature risk to patients who can gain entry into the nurses station.


Unit 200

This unit was an adolescent unit. Interview with staff #3 revealed, the adolescent patients were allowed to exercise in a large fenced yard area. Staff #3 confirmed that they escorted the adolescent patients out to the yard by going through the pediatric unit. The adolescent unit did not have a private exit into the secure yard.

Staff #3 confirmed the staff could not protect the safety of all the patients on the adolescent unit. This staff member explained how a 15 year old male adolescent patient (patient #4) had been transferred to the pediatric unit for his own safety when two older adolescents boys began to bully him. Punches were thrown and the 15 year old sustained a fall resulting in his head striking the floor. He was sent to the Emergency Department for suspected closed head injury. The 15 year old remained a patient on the pediatric unit for 2-3 days until the older boys could be safely discharged.

On 8/8/2019, staff #4, the Chief Executive Officer, was interviewed regarding the assault of a 15 year old adolescent that eventually resulted in his transfer to the pediatric unit. She stated that the transfer occurred because the 15 year old was being bullied by two older adolescents. When asked why her staff was not capable of protecting a 15 year old from being bullied in a closed and monitored environment, she responded, "Well, he was Gay". When asked if that was reason for bullying that ended in a trip to the Emergency Department, she replied, "no". Staff #4 gave no explanation why staff, if in sufficient numbers, could not protect a patient from assault.


Review of patient #4's Medical record revealed, he was admitted 7/7/2019. On 7/26/2019, the 06:59 nurses note recorded, "pain in joint and head after fight. was kicked in the hip area with falls (sic). Sustained hard fall hitting right side of head with breakage of skin due to fall. Complains of some headache but not the worst headache of life". No earlier nursing documentation found in the patients medical record. On 7/26/2019, Pt #4 was sent to the Emergency Department for a CT and MRI of his head. (Computed Tomography and Magnetic Resonance Imaging) no injury identified.

A review of the aggressive male peer patient #9's medical record revealed the following: He was admitted 7/22/2019. On 7/25/2019, 1930, "after shift change patient was in the day area on (sic) the nurses desk, had verbal altercation with male peer an threatening a male peer to have a fist fight. Staff verbally intervened but unable (sic) to follow direction and continue fighting with peers. Patient warned the consequence of behavior and unit guidelines agreement discussed. safety precautions maintained related to aggression behavior, male peer fell on the ground patient continued kicking as staff tried to separate him".

Interview with staff #3 confirmed there was not enough staff present to keep the boys separated. One of the boys was extremely aggressive and some staff were fearful of him.


Unit 400

This unit was observed with patients whose age ranged from 18 to over 65. Three patients were observed with walkers and one patient was observed in a wheel chair. Staff #3 confirmed, the staff were concerned over any angry patient using a walker as a weapon aimed at another patient or the staff.

Staff #3 offered that the patient in the wheel chair could not access the toilet, shower, or sink in his room because it was not handicap accessible. If the patient had to use the toilet, a staff member had to remove him from the unit and take him to the center of the building which has the only toilet with a door wide enough to accommodate his wheel chair. The patient required minimum to moderate assistance and this pulled a staff member from the unit for an extended period of time leaving the staff further short handed.

During this observation, an unidentified female patient opened the nurses station half door and walked behind the nurse (nurse was speaking with another patient) into the common space between unit 400 and unit 500. An interview with staff #3 confirmed, this female patient had done this before and actually entered the 500 unit and stood behind the unit nurse. She was easily redirected back through the open doorway to unit 400.

A review of the medical record for patient #2 indicated, she was a patient by court order. Medical record for 8/2/2019 revealed the following: "Patient says she had sex with male peer that was previously on the unit". This was the only documentation of this event. However, interview with staff confirmed patient #2 was observed on top of a male peer in his room. She was told to go to her room and the male peer was observed pulling up his pants. The male peer denied the sexual intercourse. Later the male peer confirmed he and patient #2 had sexual intercourse.

Staff #3 indicated there simply was not enough staff to keep an eye on everyone.


Unit 500

This unit served the needs of acute psychiatric patients. Staff in this unit voiced their concern that they were not sufficiently staffed to protect each other, the facilities computers which were easily accessible over the nurses station counter, or other patients. The unit was small and the common area was very small. Staff could not monitor the very small court yard when a patient went out side and monitor the remaining patient inside the unit, especially when line of sight must be maintained.



10135


During confidential staff interviews the following was stated:

"400 unit has a lot of psychotic patients. Not enough staff. The unit was crowded and there was no where for the patients to sit and eat. It so crowded at times they bump into to each other and it makes them irritated. The behaviors have increased on the unit."


"the restraint seclusions had risen to an UnGodly amount. "


"Today (08/07/19) on 400 unit we are short 2 people (1 RN and 1 tech) and we have 11 patients. We had a call in today. Staffing is a nightmare. There are more staff injuries and a nursing supervisor got a concussion about 1.5 weeks ago on the adolescent unit. A kid rammed her and she fell and hit her head. The administrator controls the staffing. She has been told about 400 unit being too small and the concerns with the patients. Everything is the administrator's decision, she is the administrator on call every night."


"Today on 400 unit we have 11 patients, 2 RN's and 1 tech. We are supposed to have another tech. The techs are supposed to monitor every one of the patients every 15 minutes. They have to go to every room and check them. The space over there is not large enough, it's too compacted. There's a lot of conflict with patients at this time because of the space. We need more nurses and techs for this unit".


"The front lobby is unattended on the weekends. A tech has to be pulled from 2:30 -4:30 p.m. to man it because there is no operator.


"There's really no acuity level for us to use with the psych patients."


"The Administrator controls who can be admitted or not. When you tell them a patient is not safe to be admitted to the facility it's disregarded."

"The techs are given level 2 and level 3 patients. Level 2 means the patient has to remains in your line of sight and level 3 means the patients are at arm's length. Hall check means we go to each individual room and make sure the patients are safe.


"The techs are given Level 2 patients and hallway duty at the same time. You cannot do both at the same time. The Level 2 patient sometimes has to be left unattended.


Unit 500 has 26 beds and the tech has to watch all the patients. It's almost impossible."

"The techs are responsible for basic care of patients, vital signs, observation rounds, assisting with meals, providing snacks, and activities of daily living care."


Review of staffing sheets for the timeframe of 07/20/2019 - 08/06/2019 revealed the following:

Hall 400

On 07/20/19 there was a shortage of 1 tech on both shifts.

On 07/21/19 there was a shortage of 2 techs on both shifts. The 1 tech working was on "status" (meaning monitoring patients on Level 2 or 3) and hall duty( monitoring of patients in hallway and/or in patient rooms).

On 07/22/19 there was a shortage of 1 nurse and 1 tech on day shift.

On 07/23/19 there was a shortage of 1 tech on day shift.

On 07/24/19 there were 11 patients on the evening shift. There were 2 Registered Nurses (RN), 1 Licensed vocational nurse (LVN) and 1 tech. According to the "Staffing Matrix" there were supposed to be 3 RN's and 2 Mental health techs (MHTs). The matrix did not mention the usage of an LVN in place of an RN. The facility was short a RN and 1 tech.

On 07/25/19 there were 11 patients on the evening shift. There were 2 RNs, 1 LVN and 1 tech. According to the "Staffing Matrix" there were supposed to be 3 RN's and 2 MHTs. The matrix did not mention the usage of an LVN in place of an RN. The facility was short a RN and a tech.

On 07/26/19 there was a shortage of 2 techs on both shifts. The 1 tech working was on "status" (close monitoring of patients on Level 2 or 3 ).

On 07/27/2019 there were 11 patients on the evening shift. There were 2 RNs, 1 LVN and 1 tech. According to the "Staffing Matrix" there were supposed to be 3 RN's and 2 MHTs. There was one tech listed, but the tech was on "status" (monitoring a Level 2 or 3 patient). The matrix did not mention the usage of an LVN in place of an RN. The facility was short a RN and 2 techs.

On 07/28/2019 there were 12 patients on the day shift. There were 3 RNs and 1 tech on status. According to the "Staffing Matrix" there were supposed to be 3 RN's and 2 MHTs. There was one tech listed, but the tech was on "status".

There were 11 patients on the evening shift. There were 2 RNs and 1 tech. The other tech listed was on "status". According to the "Staffing Matrix" there were supposed to be 3 RN's and 2 MHTs. The facility was short 1 RN and 1 tech.

On 07/29/2019 there were 12 patients on the day shift. There were 3 RNs and 1 tech on "status". According to the "Staffing Matrix" there were supposed to be 3 RN's and 2 MHTs. The facility was short 2 techs.

On 07/30,07/31, 08/02, 08/03, 08/04 and 08/05/2019 the facility was short 1 tech on either the day or night shift.

On 08/06/2019 there were 11 patients on the evening shift. There were 2 RNs and 1 tech. According to the "Staffing Matrix" there were supposed to be 3 RN's and 2 MHTs. The facility was short 1 RN and 1 tech.


Hall 500

The facility was short either 1 or 2 techs on the following days:

On 07/20 (evening shift), 07/21 (day and evening shift), 07/22(day shift), 07/23 (evening shift), 07/25 (day and evening shift), 07/28 (day and evening shift),07/30 (evening shift), 07/31 (day and evening shift),08/04(day and evening shift), and 08/06(day and evening shift).


Hall 200

On 07/21/2019 there were 8 patients on day shift. There was 1 RN, 1 tech, and 1 tech on "status". According to the "Staffing Matrix" there were supposed to be 2 RN's and 1 MHT. The facility was short 1 nurse.

On 07/26/2019 there were 10 patients on the evening shift. There was 2 RN, and 3 techs who were on "status". All of the techs were on "status" and could not be counted in the staffing. According to the "Staffing Matrix" there were supposed to be 2 RN's and 1 MHTs.

On 07/27/2019 there were 10 patients on day shift. There was 2 RN, 1 RN on "status", and 1 tech on "status".
All of the techs and the extra nurse were on "status" and could not be counted in the staffing. According to the "Staffing Matrix" there were supposed to be 2 RN's and 1 MHTs.

On 07/29/2019 there were 8 patients on day shift. There was 3 RN's and no techs. One of the RNs were on "status" with a patient. The extra nurse was on "status" and could not be counted as a tech. According to the "Staffing Matrix" there were supposed to be 2 RN's and 1 MHTs.

Staff # 11 confirmed the staffing numbers.


Review of a facility's policy named "BHC Patient Special Precaution Levels." Dated 12/19/2018 revealed the following:

"Purpose: To promote patient safety by identifying safety risks and assigning a special precaution level and clinical precautions in the least restrictive manner possible.

Policy: To ensure a safe environment and prevent patient harm, all patients will be assigned applicable precautions and a safety status. All patients, regardless of precautions or safety level will be monitored no less.

Level 3- Severe Risk ... Strict 1:1 (arm's length at all times) with 15 minutes observations...

Level 2- HIGH RISK .... (Constant Observation) with 15 minute observations. This is a strict line of sight observation of the patient at all times by an assigned staff member of the same gender. This line of sight observation includes grooming and hygiene activities and sleep ...

Level 1- LOW TO MODERATE RISK ...Close Observation. This observation status is ordered for patients who are determined to be at moderate risk but can be monitored every 15 minutes.
Requires an observation rounds sheet entry every 15 minutes ..."


39801


Confidential interviews on August 7, 2019 after 9:00 a.m. revealed the following:

"The Acute unit was moved from 300 to 400 Unit. It has been horrible for staff and patients. The patients have no means to obtain quiet time or privacy. All rooms are semi-private. There is a court yard that is small and does not offer any privacy. Since the unit was moved from 300 to 400 there has been an increase in aggressive behavior and assaults. The restrains have increased. We can hold approximately 18 patients here. There are only kitchen table accommodations for 8 patients. All other patients must sit with the tray in their lap on a bench. Patients are more aggressive because the behaviors are escalated by other patients in more close quarters. When one patient acts out, all the patient's aggressive behavior escalates. We have had an increase in patient complaints on unit 500, which is adjacent to unit 400 because of the increase in noise from unit 400. Patient have more open access to nurse's desk. There have been incidents documented where patients reached over the desk and destroyed equipment. Patients have grabbed staplers and used as weapons for aggression towards patients and staff. The administrator has been aware of these concerns and did nothing to alleviate safety concerns."

"There has been an increase in aggression towards staff since the move was completed. There has been an increase in restraints on unit 400 from unit 300."

"Staff have no input on admissions. If the staffing is inappropriate, the administration does not care. Staff are told to accept the patient. The Administrator controls all admission and does not listen to staff concerns.""

"Administrator does not listen to staff concerns about admissions when the facility does not have staffing to cover. "

"There is a safety concern for staff and patients on Unit 400. There was a patient that got past the nurse desk on Unit 400 (Acute) and went to through the Medication room and accessed Unit 500 (Adult) prior to being confronted."

"Unit 400 is small and does not allow for patients to have quiet time/alone time. When one patient is agitated, the whole unit is escalated."

"The facility accepts patients that the staff cannot accommodate. There is only one shower that can accommodate wheelchair patients in the facility. We have patients on units that require staff to leave the unit and transport the patient to another unit to access showers that will accommodate wheel chair accessible showers. This requires staff to go off the unit, creating patient safety issues. "


Review of the facility restraint log for January 2019 to August 7-2019 revealed the following:

January 2019 - 6 restraints - None on the acute unit.

February 2019 - 12 restraints - One on the acute unit (300)

March 2019 - 7 restraints - 2 on the acute unit (300)

April 2019 - 14 restraints - 4 on the acute unit (300)

May 2019 - 3 restraints - None on the acute unit

June 2019 - 6 restraints - None on the acute unit.

(ACUTE MOVED FROM Unit 300 TO Unit 400)

July 2019 - 34 restraints - 22 on the acute unit.

August 2019 - 2 restraints - both on the acute unit.



Review of the facility Incident Log revealed the following:

June 2019 - 1 incident logged that involved patient assaulting another patient.

(ACUTE MOVED from Unit 300 to Unit 400)

July 2019 - 21 incidents logged that involved aggressive behavior by the patient, staff assault by a patient, or patient behavior requiring restraints.


Staff #1 confirmed the restraint log and incident log were accurate and up to date.